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ection Report.Numb <br /> == _ Waste Tire SuYiy & Inspection Report in <br /> er■ <br /> J.1 <br /> State of California <br /> crn Cgrated Waste <br /> eManag) Survey Form - Page 1 1 '1 - 1 0 O 6141 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />} TPID- Inspection Type (Fill one) <br /> Site Suffix: I j I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: / <br /> v�, 0,t s.� �[,{t�-r l` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- <br /> Inspected By Inspector <br /> - <br /> Physical Address <br /> < � � f I �✓ t � <br /> Street � <br /> Inspection Date <br /> 1 i Time In Time Out <br /> City V State ZlP Code <br /> Business Rep Title OAM Q AM <br /> PM .i <br /> 5V J 3 Q I 5 <br /> PM <br /> �I, Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ❑f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active 0 Passenger (2 Generator Q Outdoor <br /> r-,-� 0 Q Closed Q Altered <br /> GPS Latitude 1 I I Q Hauler Q Indoor <br /> O Q Inactive 9 Truck <br /> Longitude — Q Planned 0 OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repairs Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part 6 - <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> A.,HAULING AND MAMIFF-AT REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§184 .1 (a)(b)(c)-Tire Program ID Number from CIWMB . <br /> Q Q 14 CCR§1845912.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NO or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> .0 .Q• Other: § <br /> Comments �bv (-(1�Q.. 1001 (ioo DI Uvkhe4j i/-jO�i rC)je � tl ` jlt, <br /> I"j;i C'Ps^ it ! C��'f. r�ldff � I1 Jt< { t i1� � Z �✓(�Cl rig, /eiL'�t{�.tf <br /> J� <br /> ✓ryr,tt � � t"t ��✓,t4 coil Ytrc G�t ��.c;rF<( Or►t { a i�.l'<` C �= , ('7L f <br /> }P1/ I _, ✓I-Q✓f, U (GM&SOU Ad. ( )t) lLlO1Q ' LI'F . <br /> Inspection Form Included Q ;?s ��fes. <br /> fie. ri, <br /> Comments Included: 'Business`IRep's Signature <br /> i_natur•e ; Phone Number Inp.ector's S�i atriP.'-h.-o--n- <br /> e Number <br /> 62081 <br /> INSTRUCTIONS X _VF � p ,i )V <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> ( <br />